PROBLEMS RELATED TO ABUSE OR NEGLECT
DSM-IV
IF FOCUS OF ATTENTION IS ON THE VICTIM [SURVIVOR]:
995.52 Neglect of child
995.53 Sexual abuse of child
995.54 Physical abuse of child
995.81 Physical abuse of adult
995.83 Sexual abuse of adult
IF FOCUS OF ATTENTION IS ON THE PERPETRATOR [OFFENDER] OR ON THE RELATIONAL UNIT IN WHICH BEHAVIOR OCCURS:
V61.21 Neglect; physical or sexual abuse of child (specify)
V61.12 (Physical or sexual abuse of adult by partner)
V62.83 (Physical or sexual abuse of adult by person other than partner)
Abuse affects all populations and is not restricted to specific socioeconomic or ethnic/cultural groups. Although “violence” means the use of force or physical compulsion to abuse or damage, the term “abuse” is much broader and includes physical or mental maltreatment and neglect that result in emotional, physical, or sexual injury. In the case of children, the disabled, or elderly, abuse can result from direct actions or omissions by those responsible for the individual’s care. Additionally, one’s perception of abuse is affected by cultural and religious practices, values, and biological predispositions. The problem can be generational, with victimizers often being victims of abuse themselves as children.
Violence is not a new problem; in fact, it is probably as old as humankind. However, in the United States, medicine has focused on these issues only since 1946. Therefore, the parameters of abuse are being identified and redefined on what seems to be an almost daily basis. For example, until recently women and children were considered the personal property of men and they did not own property or have rights of their own. Women viewed themselves as sexual objects and were expected to subjugate themselves/defer to the will of men. Harsh treatment of children was justified by the belief that corporal and/or excessive punishment was necessary to maintain discipline and instill values. Changes in societal beliefs and the enactment of new laws have done little to curb abuse. Today, battering is the single most common cause of injury to women, and there has been an increase in the incidence of child abuse and neglect-related fatalities reported to child protection service agencies in the United States. Whether these statistics represent an increase in incidents or are the result of changing attitudes and/or better reporting is much debated. The Centers for Disease Control and Prevention has declared violence to be a public health problem.
This plan of care addresses the problems of abuse and neglect in both adults and children and includes both the person who offends and the survivor of the offense.
ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory suggests that unmet needs for satisfaction and security result in an underdeveloped ego and a poor self-concept in the individuals involved in violent episodes. Aggression and violence supply the offender with a sense of power and prestige that boosts the self-image and provides a significance or purpose to the individual’s life that is lacking. Some theorists have supported the hypothesis that aggression and violence are the overt expressions of powerlessness and low self-esteem. The same dynamics promote acceptance in the person who is the victim of violence.
Biological
Various components of the neurological system have been implicated in both the facilitation and inhibition of aggressive impulses. The limbic system in particular appears to be involved. In addition, higher brain centers play an important role by constantly interacting with the aggression centers. Various neurotransmitters, such as epinephrine, norepinephrine, dopamine, acetylcholine, and serotonin, may also play a role in facilitation and inhibition of aggressive impulses. This theory is consistent with the “fight-or-flight” arousal in response to stress.
Some studies suggest the possibility of a direct genetic link; however, the evidence for this has not been firmly established. Organic brain syndromes associated with various cerebral disorders have been linked to violent behavior. Particularly, areas of the limbic system and temporal lobes, brain trauma, and diseases such as encephalitis and disorders such as epilepsy have been implicated in aggressive behavior.
Family Dynamics
Child abuse is often the consequence of the interactions of parental vulnerabilities (e.g., mental illness, substance abuse); child vulnerabilities (e.g., low birth weight, difficult temperament); a particular developmental stage, such as toddler, adolescence; and social stressors (e.g., lack of social supports, young parental age, single parenthood, poverty, minority ethnicity, lack of acculturation, exposure to family violence).
Learning theory states that children learn to behave by imitating their role models, usually parents, although as they mature they are influenced by teachers, friends, and others. Individuals who were abused as children or whose parents disciplined them with physical punishment are more likely to behave in a violent manner as adults. Television and movies are believed to have an influence on developing both adaptive and maladaptive behavior. Some theorists believe that individuals who have a biological influence toward aggressive behavior are more likely to be affected by external models than those without this predisposition.
The influence of culture and social structure cannot be discounted. Difficulty in negotiating interpersonal conflict has led to a general acceptance of violence as a means of solving problems. When individuals/groups of people discover they cannot meet their needs through conventional methods, they are more likely to resort to delinquent behaviors. This may contribute to a subculture of violence within society.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Sleep problems (e.g., sleeplessness or oversleeping, nightmares, sleepwalking, sleeping in strange place [avoiding offender])
Fatigue
Ego Integrity
Negative self-appraisal, acceptance of self-blame/making excuses for the actions of others
Low self-esteem (offender/survivor)
Feelings of guilt, anger, fear and shame, helplessness, and/or powerlessness
Minimization or denial of significance of behaviors (most prominent defense mechanism)
Avoidance or fear of certain people, places, objects; submissive, fearful manner (particularly in presence of offender)
Report of stress factors (e.g., family unemployment; financial, lifestyle changes; marital discord)
Hostility toward/mistrust of others
Threatened when partner shows signs of independence or shares self/time with others (offender)
Elimination
Enuresis, encopresis
Recurrent urinary infections
Changes in tone of sphincter
Food/Fluid
Frequent vomiting; changes in appetite: anorexia, overeating (survivor)
Changes in weight; failure to gain weight appropriately/signs of malnutrition, repeated pica (neglect)
Hygiene
Wearing clothing that covers body in a manner inappropriate for weather conditions (abuse), or that is inadequate to provide protection (neglect)
Excessive/anxiety about bathing (abuse); dirty/unkempt appearance (neglect)
Neurosensory
Behavioral extremes (very aggressive/demanding conduct); extreme rage or passivity and withdrawal; age-inappropriate behavior
Mental Status:
Memory: Blackouts, periods of amnesia; reports of flashbacks
Disorganized thinking; difficulty concentrating/making decisions
Inappropriate affect; may be hypervigilant, anxious, depressed
Mood swing—“dual personality,” extremely loving, kind, contrite after battering episode (offender)
Pathological jealousy; poor impulse control; limited coping skills; lacks empathy (offender)
Rocking, thumb sucking, or other habitual behavior; restlessness (survivor)
Psychiatric manifestations (e.g., dissociative phenomena including multiple personalities (sexual abuse); borderline personality disorder [adult incest survivors])
Presence of neurological deficits/CNS damage without external injuries evident (may indicate “shaken baby” syndrome)
Pain/Discomfort
Dependent on specific injuries/form of abuse
Multiple somatic complaints (e.g., stomach pain, chronic pelvic pain, spastic colon, headache)
Safety
Bruises, bite marks, skin welts, burns (e.g., scalding, cigarette), bald spots, lacerations, unusual bleeding, rashes/itching in the genital area; anal fissures, skin tags, hemorrhoids, scar tissue, changes in tone of sphincter
Recurrent injuries; history of multiple accidents, fractures/internal injuries
Description of incident incongruent with injury, delay in seeking treatment
Lack of age-appropriate supervision, inattention to avoidable hazards in the home (neglect)
Intense episodes of rage directed at self or others
Self-injurious/suicidal behavior; involvement in high-risk activities
History of suicidal behavior of family members
Sexuality
Changes in sexual awareness or activity, including compulsive masturbation, precocious sex play, tendency to repeat or reenact incest/abuse experience; excessive curiosity about sex; sexually abusing another child; promiscuity; overly anxious/ inhibited about sexual anatomy or behavior
May display feminine sex-role stereotypes; confusion about sexuality (male survivors); may have unconscious homosexual tendencies (male offenders of incest)
Reports of decreased sexual desire (as adult), erectile dysfunction, premature ejaculation, and/or anorgasmia; dyspareunia, vaginismus; flashbacks during intercourse; inability to engage in sex without anxiety
Episodes of marital rape or forced intercourse
Impaired sexual relationship between parents (incest)
Parent/female careprovider aware or strongly suspects incestual behavior, may be grateful not to be focus of partner’s sexual demands
Obstetrical history of preterm labor, abruptio placentae, spontaneous abortions, low birth weight, fetal injury/death (1 in 6 pregnant women are battered during pregnancy); lack of prenatal care until 3rd trimester (abused women twice as likely to delay care)
Vaginal bleeding; linear laceration of hymen, vaginal mucosa
Presence of STDs, vaginitis, genital warts, or pregnancy (especially child)
Social Interactions
Multiple family/relationship stressors reported
Household members may include step-relatives or a paramour
History of frequent moves/relocation
Few/no support systems
Lacks knowledge of appropriate child-rearing practices (child abusers)
Inability to form satisfactory peer relationships; withdrawal in social settings; inappropriate attachment to imaginary companion
Very possessive, perceives partner as a possession; repeatedly insults/humiliates partner, strives to isolate partner from others/keeps partner totally dependent, challenges partners honesty, uses intimidation to achieve power/control over partner (offender)
Lack of assertive communication skills; difficulty negotiating interpersonal conflicts
Cheating, lying; low achievement or drop in school performance
Running away from home/relationship
Parent may interfere with child’s normal peer relationships to prevent exposure (incest)
Memories of childhood may contain blank periods, excessive fantasizing/daydreaming; report of violence/neglect in family of origin
Family Interaction Pattern: Less verbally responsive, increased use of direct commands and critical statements, decreased verbal praise or acknowledgment, belittling, denigrating, scapegoating, ignoring; significant imbalance of power/use of hitting as control measure, patterns of enmeshment, closed family system; one parent domineering, impulsive; other partner passive, submissive
Teaching/Learning
May be any age, race, religion/culture, or educational level; from all socioeconomic groups (usual child profile is under age 3 or perceived as different due to temperamental traits, congenital abnormalities, chronic illness)
Learning disabilities include attention-deficit disorders, conduct disorders
Delay in achieving developmental tasks, declines on cognitive testing; brain damage, habitual truancy/absence from school for nonlegitimate reasons (neglect)
Substance abuse by individuals involved in abuse/neglect, or other family member(s) (most often cocaine, crack, amphetamines, alcohol)
Use of multiple healthcare providers/resources (limits awareness of repeated nature of problem); lack of age-appropriate health screening/immunization, dental care, absence of necessary prostheses, such as eyeglasses, hearing aid (neglect)
DIAGNOSTIC STUDIES
Physical and Psychological Testing
dependent on individual situation/needs
Screening Tests (e.g., Child Behavior Checklist): Elevated scores on the internalization scale reveal behaviors described as fearful, inhibited, depressed, overcontrolled or undercontrolled, aggressive, antisocial.
NURSING PRIORITIES
1. Provide physical/emotional safety.
2. Develop a trusting therapeutic relationship.
3. Enhance sense of self-esteem.
4. Improve problem-solving ability.
5. Involve family/partner in therapeutic program.
DISCHARGE GOALS
1. Physical/emotional safety maintained.
2. Trusting relationship with one person established.
3. Self-growth and positive approaches to problems evident.
4. Client/SOs participating in ongoing therapy.
5. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS TRAUMA, risk for
Risk Factors May Include: Dependent position in relationship(s)
History of previous abuse/neglect
Lack or nonuse of support systems/resources
Possibly Evidenced by: [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Desired Outcomes/Evaluation Criteria— Be free of injury/signs of neglect.
Client Will:
Client/Family Will: Recognize need for/seek assistance to prevent abuse.
Identify and access resources to assist in promoting a safe environment.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Note age/developmental level of
survivor, Children under 3, those
perceived as having
mentation, agility, physical abilities/limitations. different
temperament, or those with congenital
problems/chronic
illness are at increased risk of
being
abused/neglected. Additionally, the elderly
who
are dependent on others because of age/
infirmities
or individuals with significant
disabilities
are also at risk. Those who are
incapable
of meeting their own needs/directing
their
personal affairs may require alternate
placement/court-ordered
advocate.
Review physical complaints/injuries including those The
visible evidence of physical abuse/neglect
that suggest possibility of sexual abuse (e.g., bladder makes
it more easily recognized. Although these
infection, bruises in the genital area, reports of clients
display signs of emotional involvement,
aggression or inappropriate sexual behavior). Note inappropriate
affect, and behaviors such as
affect and demeanor. withdrawal,
acting out, or suicidal gestures in the
absence
of physical evidence of abuse/neglect,
suggests
presence of emotional abuse. Child sexual
abuse
is particularly difficult to diagnose.
Although
the signs noted here are not definitive,
they
suggest need for further investigation.
Identify individual concerns of client. Concerns
will vary dependent on individual
circumstances
and affect choice of interventions,
possible
options.
Interview offender(s)/family in a nonjudgmental Can
provide insight into risks to client and
manner, displaying tact and professional concern potential
for repetition of behavior. The need for
for individual(s). power
over or control of survivor, excessive
jealousy/overpossessiveness,
frequency of verbal
arguments
that can escalate to violence, substance
abuse,
severity of past injuries inflicted, history of
forced
or threatened sexual acts, and/or threats to
kill
client (especially when offender indicates a
belief
he or she cannot live without partner)
greatly
increases the level of concern for survivor’s
safety
and choice of interventions.
Maintain objectivity and avoid blame or accusations Individuals
will be defensive and may react with
during interview process. hostility
and anger, or may withdraw, making it
difficult
to obtain accurate information. Initially,
offender
may not be known, and even if family is
not
involved in situation, members may feel guilt
that
they did not protect the survivor. Avoiding
blame
promotes open communication and
therapeutic
interactions and may enhance the
investigation
process.
Use open-ended questions with gentle, caring Survivor
and parent/family members will
manner. Speak at individual’s level (e.g., child vs. respond
more positively to caring approach and be
adult, or developmentally disabled individual). more
available for help to correct underlying
Provide privacy as indicated by age, circumstances problems
when dealt with in this way. Note: Care
of the situation. must
be taken to avoid leading the child survivor,
or
suggesting answers to questions. As these
individuals
are vulnerable, they are suggestible
and
may provide answers to “please” the
therapist,
resulting in questionable information.
Use techniques of play therapy to obtain information The
child may be afraid to tell/be unable to
from children. Videotape session(s) as appropriate. adequately
verbalize what has happened. Play
therapy
is a nonthreatening method of
observation/Active-listening
that allows for free
expression
of the child’s feelings and perceptions
without
undue influence from adults. Videotaping
allows
various parties (legal and counseling) to
view
the same data, reducing risk of
misinterpretation
and negating need for child to
submit
to repeated questioning, which may color
data
over time. In addition, this can provide
safeguards
for both therapist and survivor.
Note sequence of events as related by parent(s)/ May
reveal reality of what happened.
caregivers or partner, paying particular attention to Offender(s)/family
members are upset and afraid
inconsistencies and contradictory reports. about
what has happened/the potential
consequences
and may try to cover up
circumstances
of injury.
Evaluate family and home environment. Note Provides
clues to need for change to prevent
particularly areas of stress related to abusive further
problems. Families who move their
occurrence. residence
frequently and are socially isolated, and
stepfamilies
are at greater risk. Children who have
been
separated from parents because of
prematurity
or neonatal illness also may be more
at
risk, owing in part to problems with bonding
and
situational stressors (e.g., financial concerns,
demands
of caregiving role).
Identify individual risk factors for recidivism of Offender’s
resistance to ongoing therapy,
abuse/neglect. substance
abuse, immaturity, and narcissistic
personality
traits increase risk that violent
behavior
will recur.
Help adult survivor develop a safety plan Typically,
these individuals have few/are
incorporating available personal and community separated
from support systems and require
resources. assistance
to identify options and initiate a plan.
Additionally,
availability of resources such as
women’s
shelters, counseling services, or
ombudsman
for the elderly/disabled varies
according
to locality.
Discuss importance of involved adults participating Without
outside intervention, the behavior is
in therapeutic program. Identify consequences of likely
to continue. Loss of family (divorce,
abusive behaviors. separation,
restraining order, alternate placement),
loss
of property/income, possible loss of job, as
well
as potential for incarceration can occur.
Studies
indicate skilled specialized counseling has
a
success rate of 50%–75% in eliminating violent
behavior.
Collaborative
Follow correct procedures and be familiar with Legal
obligations vary from state to state, but most
reporting protocols of institution/community. states
have mandatory reporting of suspected
child
abuse and some have added mandatory
reporting
for adults as well. Sensitive handling of
this
procedure can provide protection for the client
and
direct families to the help they need to
promote
improved functioning.
Arrange for home-based interventions
(e.g., visiting Home visitation/support provides opportunity
for
nurse, First Visitor, Bright Beginnings) as indicated. teaching/modeling
of effective child rearing
behaviors,
ongoing monitoring of home situation,
and
early identification of/intervention for
developing
problems to help maintain the family
unit.
Refer to individual/family therapy. As
in the case of violent behavior, involved
individuals
need to distinguish between validity of
emotions
and the inappropriateness of behavior.
Violence
is the choice of the offender, is under his
or
her control, and is his or her sole responsibility
although
the dynamics of relationship(s) may be a
factor.
Refer individuals to substance abuse program, as Substance
abuse has a negative impact on the
appropriate. therapeutic
process and increases likelihood that
behavior
will recur/continue.
NURSING DIAGNOSIS SELF ESTEEM, chronic low
May Be Related to: Personal vulnerability, feelings of abandonment, circular process of self-negation
Life choices perpetuating failure/abuse
Possibly Evidenced by: Self-negating verbalization, expressions of shame/guilt
Evaluating self as unable to deal with events
Rationalizing away/rejecting positive feedback and exaggerating negative feedback about self
Hesitancy to try new things/situations; nonassertive/passive, indecisive, or overly conforming behaviors
Desired Outcomes/Evaluation Criteria— Verbalize understanding of negative evaluation of
Client Will: self and reasons for this problem.
Participate in treatment program to promote change in self-evaluation.
Demonstrate behaviors/lifestyle changes to promote positive self-esteem.
Verbalize increased sense of self-esteem in relation to current situation.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Develop therapeutic relationship. Be
attentive, Promotes self-esteem by validating the
individual
validate client’s communication, provide as
a worthwhile person who has important things
encouragement for efforts, maintain open to
say and has value in the situation. This
communication, use skills of Active-listening and relationship
may be slow to develop because
“I-messages.” client’s
feelings of betrayal will influence ability
to
trust others as well as herself or himself. Note:
Males
who have been sexually abused may have
difficulty
with self-disclosure to male therapists,
and
young children may fear being seduced by
male
therapist or be concerned that female
therapist
will not act in a protective manner.
Note body language and hypervigilant
attitude. After period of testing reliability of
caregiver/therapist,
client may begin to relax
vigilance,
indicating initiation of trust relationship
and
openness to progress in therapy.
Assess content of negative self-talk. “Damaged
goods” syndrome and self-blame for
what
has occurred are common. Additionally, this
may
be reinforced by negative responses by
individuals/peers,
hostility from family members,
and
inner feelings of shame/guilt. Depending on
severity,
this will likely be the initial focus of
therapy
once survivor safety is assured.
Discuss survivor’s perceptions of self related to Client
frequently believes she or he is “lacking” or
what is happening. Confront misconceptions. in
some way causing the behavior in the other
person.
Gently confronting these misperceptions
can
help client accept the reality that she or he is
not
responsible for the other’s behavior.
Emphasize need for client to avoid comparing self Pattern
has been established to make unfavorable
to others. comparisons,
and stopping this thought process is
a
step toward increasing client’s self-esteem.
Be aware that people are not programmed to be In
order to develop positive self-esteem,
rational—rather, it is a learned behavior/skill. individual
needs to seek information/facts, choose
to
learn, choose to think rather than merely
accepting/reacting
to what is happening, to
respect
self and value honesty.
Confront client’s tendency to minimize
situation. Gentle confrontation can help the client
begin to
Discuss impact of abuse/neglect on individual. accept
the reality of what has happened. Giving up
the
“fantasy” of “things as you wish they were”
provides
a stronger base for client to build on,
enhancing
likelihood of successful outcome.
Proceed with caution when helping
client recall/ While the concept of repression
has long been
investigate areas of life that have been forgotten. accepted
in psychology, the phenomenon of “false
memories”
has raised questions regarding the
validity
of what is remembered. The suggestion of
questioning
and the client’s own misperceptions
and
fantasies can lead to inaccurate conclusions
and
accusations that may be damaging to the
client
and family.
Identify what behavior does for client
(positive Promotes awareness of why things are the
way
intention, i.e., maintains dependent position, creates they
are and provides a starting point for making
sense of power). Ask what options are available to changes.
the client/SO.
Set limits on aggressive or problem
behaviors, such These behaviors diminish self-esteem, and
as acting out, suicide preoccupation, or rumination. continuation
of them interferes with recovery.
(Refer to ND: Violence, risk for, directed at self/ Rumination
locks client into a circular path rather
others.) than
allowing individual to move forward and
“get
on” with life.
Discuss inaccuracies in
self-perception with client/ Client may not see
positive aspects of self that
SO(s). Help client to recognize view of self as others
see, and bringing it to awareness may help
“the victim.” change
perception. Dwelling on/sense of being
“the
victim” can interfere with sense of worth and
impede
recovery.
Have client list current/past
successes and strengths. Helps develop internal sense of
self-worth, new
Provide feedback using positive “I-messages” rather coping
behaviors. The use of praise is external
than praise. control
and may be rejected by the individual.
Discuss past choices, helping client identify future Negative
view of self and perceived lack of
options. Avoid blaming client; assuring client that options
can interfere with client taking control of
his or her decision was the best that could be made own
life and developing new behaviors to prevent
at the time. future
abusive situations. Note: Appropriately
attributing
responsibility for the abuse to
other(s)/accepting
responsibility for own actions
as
appropriate, is an important part of healing,
allowing
client to stop self-criticism and begin
self-nurturing
and protection.
Help client identify goals that are personally Provides
direction for client to work toward. Note:
achievable and supportive of self. Clients
not only need to feel differently about
themselves
but also need to treat themselves
differently.
Allow client to progress at own rate. Adaptation
to a change in self-concept depends on
its
significance to individual, disruption of
lifestyle,
and length of illness/debilitation. Note:
Emotional
abuse (e.g., rejecting, terrorizing,
ignoring,
isolating, or corrupting) may have
continued
for a prolonged period of time before
being
diagnosed and therefore may be more
pervasive
and more difficult to overcome than
physical
abuse.
Involve in activities/exercise program. Provides
opportunities to practice new skills and
promotes
socialization; helps relieve anger/stress
and
enhance sense of general well-being.
Encourage development of social/vocational skills. Participation
in classes/activities/hobbies that
client
enjoys or would like to experience promotes
successful
accomplishments, enhancing self-worth.
Also
provides options for increased independence
and
future options.
Give positive reinforcement for progress noted. Helps
client accept self as a worthwhile person.
Positive
words of encouragement support
development
of coping behaviors.
Evaluate educational placement. Special
program may be needed to help client
overcome
educational deficiencies and catch up to
appropriate
grade level/obtain GED, etc.
Identify family dynamics past and present. Family
interactions contribute to development of
self-esteem
in family members and provide clues
to
problems contributing to abuse.
Provide age-/situation-appropriate bibliotherapy. Reading
information supplements and supports
other
therapeutic intervention.
Collaborative
Provide therapy in a team setting and seek peer Opportunity
for open discussion increases
consultation as appropriate. therapist’s
awareness of personal feelings
regarding
abuse behavior/victimization of client,
overidentifying
with client, merging with the
criminal
justice system’s (society’s) need for
retribution
or need to “rescue” client, which could
lead
to countertransference problems and interfere
with
the progress of therapy. Note: This concern
may
be of greater significance when survivor is a
child
who has been sexually abused and the
therapist
has discomfort regarding own sexuality
and
unconscious childhood fantasies.
Involve in classes such as assertiveness training, Assists
with learning skills to promote self-esteem.
positive self-image, communication skills.
Provide information about available community Influencing
one’s community through volunteer or
programs and opportunities for involvement. paid
service (e.g., abuse prevention programs or as
a
survivor advocate) allows individual to be
proactive
and view self as a contributing member
of
society, aiding in client’s own recovery process.
Refer to clinical nurse specialist, psychologist/ Type,
severity, frequency, duration, and age of
psychiatrist, group therapy is indicated. individual
at time of abuse affect recovery. Client
may
require long-term and/or specialized
therapy,
such as hypnosis. Additionally, group
therapy
provides an opportunity for sharing own
healing
with other survivors/offenders and learn
new
skills to enhance sense of self-worth.
NURSING DIAGNOSIS POWERLESSNESS
May Be Related to: Legitimate dependency on other(s) (child, elderly, disabled individual), personal vulnerability
Interpersonal interaction (e.g., misuse of power, force, abusive relationships)
Lifestyle of helplessness (e.g., repeated failures, dependency)
Possibly Evidenced by: Verbal expressions of having no control
Reluctance to express true feelings, fearing alienation from caregiver(s)
Apathy (withdrawal, resignation,
crying),
passivity; anger
Desired Outcomes/Evaluation Criteria— Express sense of control over future.
Client Will: Identify areas over which individual has control.
Engage in problem-solving activities.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Identify circumstances of individual situation Promotes
understanding of factors involved and
contributing to client’s sense of powerlessness. enables
client to begin to develop sense of control
over
self and future.
Determine client locus of control. Client
who believes problems are caused by others
(external)
will need to begin to accept own
responsibility
for being in charge of self. Making a
decision
to take control of own life is crucial to
making
changes needed to support growth.
Help client identify factors that are under own Provides
a starting point for client to begin to
control. assume
control over own life.
Identify use of manipulative behavior and reactions Manipulation
is used for management of
of client, SO(s), and healthcare providers. powerlessness
because of distrust of others, fear of
loss
of power/control, fear of intimacy, and search
for
approval. This can interfere with personal and
therapeutic
relationships.
Discuss needs openly with client. Set agreed-on Promotes
meeting needs directly and decreases the
routines for meeting identified needs. need
for client to use manipulation.
Identify when flashbacks are problem for survivor May
occur with fatigue or stress and generally
and how they may be minimized. intensify
feelings of loss of control. Avoidance of
individual
“triggers” may reduce occurrence.
Collaborative
Refer to assertiveness program. As
client learns these skills and becomes more
active/assertive
in relationships, she or he is more
likely
to set limits on the behaviors of others,
express
feelings more openly/directly, and take
control
of own life in a healthy manner.
NURSING DIAGNOSIS COPING, INDIVIDUAL, ineffective
May Be Related to: Situational/maturational crises
Overwhelming threat to self, personal vulnerability
Inadequate support systems
Possibly Evidenced by: Verbalization of inability to cope/ask for help
Chronic worry, anxiety,
depression, poor
self-esteem
Inability to problem-solve, lack of assertive behaviors
Inappropriate use of defense mechanisms (e.g., denial, withdrawal)
High illness rate, destructive behavior toward self/others
Desired Outcomes/Evaluation Criteria— Assess the current situation accurately (related to
Client Will: age, individual condition).
Identify ineffective coping behaviors and consequences.
Verbalize feelings congruent with behavior.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Help client separate issues of vulnerability from Client
blames self/others for situation without
blame. looking
at own responsibility for victim stance.
Although
this does not excuse abuse, client needs
to
change victim behaviors to gain control of self.
Active-listen and identify client perceptions/ Client
often enters the healthcare system in
understanding of current situation. Evaluate response
to a crisis. This is an opportunity to help
decision-making ability. the
client look at reality of abuse and begin to
make
changes.
Identify previous methods of dealing with life Provides
clues to coping skills that can be used for
problems. Note use of denial. personal
growth. Denial is the most prominent
defense
mechanism used by client/family
members
to protect against shame/guilt and to
preserve
intactness of the family, and it must be
dealt
with before progress can be made.
Encourage verbalization of fears and anxieties and Expressing
feelings helps client to become aware
expression of feelings of denial, depression, and of
the feelings, recognize and deal with what is
anger. Let client know that these are
normal reactions. happening.
Encourage and support client in evaluating lifestyle. Identifying
areas of life that promote abusive
Assess stressors and make plan for necessary reactions/interactions
helps client make changes
change. in
coping methods to prevent recurrences.
Collaborative
Refer to appropriate resources as indicated by May
need additional therapy/group involvement
individual situation (e.g., support groups, AA, to
learn new coping skills.
psychotherapy, spiritual resources).
NURSING DIAGNOSIS VIOLENCE, risk for, directed at self or others
Risk Factors May Include: Negative role modeling, developmental crises
History of abuse
Rage reactions; suicidal behavior
Organic brain syndrome; temporal lobe epilepsy
[Possible Indicators:] Anger, rage; fear of others
Increasing anxiety level, motor activity
Hostile threatening verbalizations; body language indicating effort to control behavior
Overt and aggressive acts
Expressed intent/desire to harm
self/others;
self-destructive behaviors, substance abuse
Desired Outcomes/Evaluation Criteria— Acknowledge realities of the situation.
Client Will: Verbalize understanding of why behavior occurs.
Identify precipitating factors/responses.
Demonstrate new skills/methods for dealing with own responses.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine underlying dynamics of individual Necessary
to determine needs/safety concerns.
situation (e.g., pattern of abuse, contributing factors
to violent behavior, relationship of involved persons
[parent/child, spouse or lover], family pattern of
communication.)
Note signs of suicidal/homicidal
intent (e.g., Allows for initiation of safety
measures to protect
statements of intent/threats, development of a plan, client/others.
Note: Association between suicidal
giving away belongings, possession of means). behavior
and physical abuse may be related to
modeling
of aggressive behavior within
family/exposure
to suicidal behavior of family
member(s)
as well as biological risk in family for
disorders
associated with suicide (e.g., substance
abuse
and affective or impulsive conduct
disorders).
Determine client’s perception of self,
impact of abuse May see self as useless, damaged goods without
on life, and future expectations. hope
for positive change/productive future, which
may
result in feelings of hopelessness and the
perception
of lacking options. Depth of rage and
extent
of feelings of powerlessness may predict
potential
for violent behavior.
Explore death fantasies when expressed
(e.g., Discussion of fantasies helps client look
at reality
“They’ll be sorry.”). of
ideas and begin to deal with them.
Note coping behaviors being used
currently by the Provides information about mechanisms
client
client (e.g., denial, helplessness, rage reaction). uses
to maintain the status quo, which may also
increase
risk for violent behavior.
Acknowledge reality of suicide/homicide
as an Acknowledging feelings helps the client begin
to
option. Discuss consequences of actions if individual look at
what might happen if actions were acted
were to follow through on intent. Ask how it will on,
own ability to control self and make choices
help client resolve problems. regarding
recovery.
Encourage appropriate expression of feelings. Promotes
awareness of feelings and ability to deal
Acknowledge reality and normalcy of these feelings. with them
in acceptable ways.
Set limits on acting-out behaviors.
Accept client’s anger without reacting
on an Client’s anger is directed at situation
and those
emotional basis. involved,
not at healthcare provider, so remaining
separate
from the client allows therapist to be
helpful
to the resolution of the anger.
Contract with client for safety. Provides
parameters to help client deal with
destructive
thoughts/actions and helps to keep
client
safe.
Assist client to learn new coping
skills (e.g., assertive Promotes sense of self-worth and
ability to control
rather than nonassertive/aggressive behavior, own
actions/situation.
effective parenting techniques).
Collaborative
Administer antidepressants as
indicated. Helps client deal with
feelings of sadness and
hopelessness
and move forward in therapy. Age of
client
and nature of abusive situation affect depth
of
client’s depression.
Refer to inpatient program as
appropriate. May require more intensive
therapy to deal with
covert
forms of self-destructive behavior (e.g.,
substance
abuse, heavy risk-taking/runaway
behavior).
Refer to community resources (e.g., social services, Helps
attain/maintain recovery program.
AA, others), as appropriate.
NURSING DIAGNOSIS FAMILY PROCESSES, altered [dysfunctional]/PARENTING, altered
May Be Related to: Situational crises (e.g., economic, illness, change in roles), developmental transitions [loss/gain of family member(s), blending of families]
Poor role model, lack of support systems; unrealistic expectation for self, infant, partner
Physical/psychosocial abuse of nurturing figure
Possibly Evidenced by: Family system does not meet its members’ physical, emotional, spiritual, or security needs
Inability of family members to relate to each other for mutual growth and maturation
Rigidity in functions, rules, roles; verbalization of inability to control child, resentment toward child, unresolved disappointment in gender or physical characteristics of child
Inattention to child needs, inappropriate caretaking behaviors, history of child abuse or abandonment, incidence of physical/psychological trauma
Desired Outcomes/Evaluation Criteria— Express feelings freely and appropriately.
Family/Parent Will: Demonstrate individual involvement in
problem-solving process.
Engage in appropriate parenting behaviors.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine composition of family, developmental Helps
identify problem areas/strengths to
stage, presence/involvement of extended family, formulate
plans to change abusive situation. Lack
use of special supports. of/ineffective
use of support systems increases risk of recidivism.
Review type, severity, duration of problem, and Affects
choice of interventions. Abuse is an act of
contribution of, as well as impact on, individual commission,
whereas neglect is considered an act
family members. of
omission. These behaviors indicate the presence
of
problems with relationships and/or parenting
skills
and individual problems such as inability to
deal
with stressors, substance abuse, mental
illness,
cognitive limitations, or criminality. Even if
the
behavior is the result of a single individual, all
family
members may be involved in the
denial/coverup
or even passive condoning of the
behavior.
Additionally, all family members will be
affected
by the disclosure of the behavior.
Assess boundaries of family members such as These
factors are critical to understanding
whether members share family identity, have little individual
family dynamics and developing
sense of individuality, seem emotionally distant/ strategies
for change. Family that pressures
not connected with one another. survivor
to heal quickly/forgive offender, blames
individual
for causing pain by disclosing situation,
fails
to acknowledge significance of abuse, or
minimizes/negates
need for counseling is
nonsupportive
and will likely impede recovery
process.
Discuss parenting techniques and parents’ Ineffective
parenting and unrealistic expectations
expectations. Review developmental levels of contribute
to abuse. Understanding normal
children. responses,
progression of developmental
milestones
may help parents cope with changes.
(Refer
to ND: Growth and Development, altered.)
Note cultural and religious factors. Beliefs
about family roles, parenting style, and
religious
beliefs may contribute to participation
in/acceptance
of practices that are seen as
abusive.
Discuss negative mode of individual
interactions. Promotes successful interactions to break
cycle of
Emphasize importance of continuous, open dialogue abuse.
Keeping family secrets is destructive and
between family members using therapeutic can
impede the change process.
communication skills.
Determine current “family rules.”
Identify areas of Rules may be imposed by adults rather
than
needed change. through
a democratic process involving all family
members,
leading to conflict and angry
confrontations.
Setting positive family rules with
all
family members participating can promote a
functional
family.
Identify and encourage use of previously successful Everyone
has positive ways of dealing with life
coping behaviors. stressors,
and when these are identified and
supported
they can help to change abusive
situation.
Discuss therapeutic concept of forgiveness for covert Forgiving
others and oneself takes time, but can
acts as well as acts of omission. free
individuals from the past, allowing them to
move
forward with life. Although forgiving does
not
condone the actions, it may help heal
relationships.
Acknowledge realities of situation and inability to Family
may not change, or relationship may be
change others. permanently
destroyed. Individual needs to go
forward
with own life and healing process.
Collaborative
Encourage family participation in multidisciplinary Participation
in family and group therapy for
team conference/group therapy as appropriate. 13–18
months increases likelihood of success as
interactional
issues (e.g., marital conflict,
scapegoating
of the abused child) can be
addressed/dealt
with. Involvement with others
can
help family members to experience new ways
of
interacting and gain insight into their behavior,
providing
opportunity for change.
Refer to classes (e.g., Parent Effectiveness), specific Can
assist family to effect positive change/
disease/disability support groups (including enhance
conflict resolution. Parents may require
substance abuse resources)/spiritual advisor as positive
role modeling to learn nonpunitive child-
indicated. rearing
techniques. Presence of substance abuse
problems
requires all family members to seek
support/assistance
in dealing with situation to
promote
a healthy outcome.
Refer family to community programs/resources When
the individual is willing to accept
(e.g., support/psychotherapy groups, social services responsibility
for past behavior, self-help
as needed). organizations
help families overcome stigma of
situation
and achieve greater self-esteem while
providing
professionally supervised treatment.
Note:
High dropout rates have been reported
when
abusive parents are referred to traditional
community
mental health clinics. Parents often
view
authority figures with suspicion and mistrust
and
require more personal approaches (e.g., 24-
hour
availability of counselors, evening and after-
hours
appointments).
NURSING DIAGNOSIS GROWTH AND DEVELOPMENT, altered
May Be Related to: Inadequate caretaking (physical/emotional
neglect or abuse)
Indifference, inconsistent responsiveness, multiple caretakers
Environmental and stimulation deficiencies
Possibly Evidenced by: Delay or difficulty in performing skills (including self-care or self-control activities) appropriate for age
Altered physical growth
Loss of previously acquired skills, precocious or accelerated skill attainment
Flat affect, listlessness, decreased responses
Desired Outcomes/Evaluations Criteria— Perform motor, social, and/or expressive skills
Child Will: typical of age group, within scope of individual capabilities.
Perform self-care and self-control activities appropriate for age/development level.
Parents/Caregivers Will: Verbalize understanding of developmental delay/deviation and plan(s) for intervention.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine existing condition(s) that contribute to May
be long-term physical/emotional abuse,
developmental deviation. Note severity/ situational
disruption, or inadequate assistance
pervasiveness of situation. during
period of crisis or transition. Identifying
individual
situation of abuse/neglect guides
choice
of interventions.
Ascertain nature of parenting/caretaking activities Provides
information about needs of family/child.
and parents’ expectations of the child (e.g., Parents’
unrealistic expectations of the
inadequate, inconsistent, unrealistic/insufficient abilities/independence
needs of the child may
expectations; lack of stimulation, inappropriate lead
to demands for behavior that the child is
responsiveness and limit-setting). unable
to accomplish or may interfere with the
developmental
process. Note: Conflict may
especially
arise during the preschool and teen
years,
when separation issues are paramount.
Identify developmental age/stage
of child, expected Baseline information notes areas of
deviation,
skills/activities using authoritative texts (e.g., Gesell) skills
affected, whether pervasive or one area of
or assessment tools (e.g., Draw-a-Person, Denver difficulty.
Helps determine options/appropriate
Developmental Screening Test). interventions.
Provide information regarding normal
growth and Helps parents/caregivers to develop
realistic
developmental process and appropriate expectations expectations
about child’s abilities and potential.
for individual child.
Note significant stressful events that
have occurred Losses and separation such as the death of a
recently in the family. parent,
divorce, or unemployment may tax the
supportive
abilities of the parents/caregivers.
Avoid blame when discussing
contributing factors. Parents usually feel inadequate and
blame
themselves
for being “a poor parent.” Note: Adding
blame
will not be helpful for changing behavior.
Support attempts to maintain or return
to optimal Providing assistance enables parents to
progress in
level of self-control or self-care activities. learning
new skills and helping child develop to
fullest
potential.
Involve parents/caregivers in
role-play, group Provides opportunities to
practice new behaviors,
activities. enhance
self-confidence and sense of self-worth.
Provide list/copies of pertinent reference materials. Bibliotherapy
provides information to encourage
questions
and additional learning.
Collaborative
Consult appropriate professional
resources (e.g., A team approach is necessary to
coordinate an
occupational/rehabilitation/speech therapists, individual
plan of care to optimize child’s growth
special education teacher, job counselor). and
development.
Encourage attendance at appropriate educational Participation
in these activities will provide parent
programs (e.g., Parent Effectiveness classes, infant with
new skills to promote effective coping and
stimulation sessions, nurturing programs). enable
avoidance of abusive/neglectful behaviors.
NURSING DIAGNOSIS SEXUAL dysfunction/SEXUALITY PATTERNS, altered
May Be Related to: Ineffectual or absent role models; impaired relationship with a significant other
Vulnerability
Physical/psychosocial abuse (e.g., harmful relationships)
Misinformation or lack of knowledge
Possibly Evidenced by: Verbalization of a problem; reported difficulties, limitations, or changes in sexual behaviors or activities
Inability to achieve desired satisfaction
Conflicts involving values
Seeking of confirmation of desirability
Desired Outcomes/Evaluation Criteria— Verbalize understanding of sexual anatomy/
Client Will: function.
Identify individual reasons/stressors contributing to situation.
Discuss satisfying/acceptable sexual practices.
Demonstrate improved communication and relationship skills.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Discuss client’s perceptions of sexuality as learned Gives
permission to the client to talk about sex and
in family/relationships. Ask client about past abuse/ in
a safe environment. Many abused individuals
sexual abuse during history taking. feel
guilty about sharing family secrets, fear
reaction
of others, and are concerned that they will
not
be believed.
Determine usual pattern of functioning
and level of Provides information about how client views
desire as well as vocabulary used by the client. sexual
activity and areas of lack of knowledge/
misinformation.
Identify sexual problems present for
the client, e.g., Sexual abuse is demonstrated in many
different
using sex as a weapon to control/dominate partner; ways
depending on the extent, duration, and
avoiding/afraid of sex; or engaging in promiscuous presence
of threat/fear of violence. Survivors and
behavior, seeing sex as an obligation; fear, anger, or offenders
require long-term therapy to change
disgust with touching (particularly sexual touching); attitudes
about sex, sense of self as a person/
feeling emotionally distant during sexual activity; sexual
being, and general feelings related to the
painful intercourse; or orgasmic difficulty. abuse.
Identify cultural, religious, and/or
value factors and Beliefs/values of client will
affect view of what has
conflicts present. happened
and feelings about situation, influencing
therapeutic
treatment program.
Note substance use/abuse. May
affect sexual function/satisfaction, requiring
therapeutic
intervention.
Avoid making value judgments and be
aware of Judgments and negative responses do not
help
own feelings and response to client expressions, client
to cope with situation and may result in
revelations, and/or concerns. client
withdrawing and not talking further.
Provide information about anatomy/physiology Lack
of accurate knowledge may contribute to
and individual situation according to client needs. problems
client is experiencing.
Note coping style exhibited. Client
may use repetition and reenactment of the
molestation/abuse
incident(s) or may avoid sexual
stimuli.
Encourage use of higher-level defenses
(e.g., Successful intervention focuses on having
the
repression, sublimation, and intellectualization) by survivors
become gradually aware of the painful
limit-setting, education, interpretation, and memories
and verbalize them instead of acting
desensitization. them
out or avoiding them. Note: Goal of therapy
is
to free individual of emotional anesthesia and
the
sense of living a “lie,” allowing client to begin
to
feel trust and tolerate intimacy.
Set limits on seductive behavior when displayed. The
difference between acceptable physically
Help client distinguish the difference between affectionate
behavior and behavior with sexual
acceptable and unacceptable behaviors. intent,
as well as respect for own and others bodily
privacy,
needs to be learned. The sexually abused
child
may have difficulty differentiating
affectionate
from sexual relationships and may be
aroused
by routine physical or psychological
closeness.
Help client learn to say “No” to sex. It
is difficult for survivors to learn to say “Yes” to
sex
until they can learn to say “No” at any time.
Encourage careful selection of future sexual partner Helps
incest/abuse survivors develop a positive
and delaying sexual activity until a friendship is sexual
experience. Individuals heal best in
established. Suggest investigation of new partner’s relationships
high in emotional intimacy and
past involvement with the criminal system in regard support
and low in expectations of sexual
to abusive behavior. interaction.
Past behavior/involvement with the
justice
system can provide clues to future
problems
that may be anticipated.
Encourage client to share thoughts/concerns with Appropriate
self-disclosure in current/future
partner. relationships
will help couple develop positive
relationship.
Identify sights, sounds, smells, and types of touch Triggers
can cause the feelings and fears to recur.
that are associated with the event/trigger flashbacks Reexperiencing
the event in a flashback is a
for the survivor. Discuss ways to minimize traumatic
occurrence and affects current
flashbacks/deal with triggers. relationship/intimacy.
Avoiding
or learning to deal with triggers helps
individual
to remain in the safety of the present.
For
example, a specific sexual position may trigger
anxious
feelings/flashbacks. Sexual partner
“allowing”
survivor to take control, choose
alternate
position can lessen these feelings,
promoting
trust and enhancing emotional growth.
Tell the client that recovery is possible. May
believe that problems will last forever, and it
can
be reassuring to hear that therapy can help the
client
gain a positive, healthy perspective on sex
and
engage in positive relationships.
Collaborative
Refer to clinical nurse specialist, professional sex Problems
may be deep-seated and require
therapist, family counseling as appropriate. specialized/prolonged
therapy.